Children, Athletics, and Orthopedic Injury

Educational Objectives

The goals of this program are to improve management of pediatric orthopedic conditions and sports injuries, and to review the orthopedic preparticipation physical examination for student athletes.  After hearing and assimilating this program, the clinician will be better able to:

1.   Communicate effectively with referring physicians when managing the child who presents with a suspected fracture.

2.   Explain some of the pitfalls in the diagnosis of fractures in pediatric patients.

3.   Discuss general guidelines for allowing a child to return to sports after an injury, and list some of the condi­tions that preclude returning to play.

4.   Summarize the basics of rehabilitation of pediatric sports injuries.

5.   Describe the elements of the orthopedic preparticipation physical examination and the pre-existing conditions the examination may identify.

Faculty Disclosure

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any per­sonal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the faculty and the planning committee reported nothing to disclose.

Acknowledgements

Dr. Kruse spoke at the Cape Cod Conference on Pediatrics for the Primary Care Physician, held July 31 to August 2, 2009, in Hyannis, MA, and sponsored by Nemours. Dr. Garrick lectured at Clinical Pediatrics, held February 12-15, 2009, in Palm Springs, CA, and sponsored by the American Academy of Pediatrics, California Chapter 2. The Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.

Pearls and Pitfalls in Pediatric Orthopedics

Richard W. Kruse, DO, MBA, Pediatric Orthopedic Surgeon, Nemours, Wilmington, DE

Bullet points: if you suspect fracture, splint it; pad any splints; be cautious with compressive wraps; reevaluate pro­cedures for getting x-rays interpreted and timeline for acting on data; “beware the jammed finger” (fingers and hands begin to heal in 7 days; makes orthopedic treatment difficult); x-rays should be centered on wrist or joint, rather than on hand; pain in wrist or forearm may indicate fracture of distal radius (can also indicate fracture of ra­dial neck); swollen elbow in child should be presumed fractured; beware unilateral hip x-ray (can miss slipped cap­ital femoral epiphysis [SCFE])

Rules for referrals: crooked or injured extremity (if significantly swollen) should be seen by orthopedist; advice for referring physician  —  allow nothing by mouth (to avoid delays); make sure approval has been given to order x-rays and to provide care; do not discuss orthopedist’s treatment with patient or family if unsure of details

Fracture pearls and pitfalls: pearl  —  growth plate injuries common; pitfalls  —  diagnosing as sprains; unossified epiphyses; inadequate x-rays; diagnosing fractures; late diagnosis of distal radius fracture due to minimal swelling; pearl  —  fractures near growth plate may not swell much; pitfall  —  radiologists do not agree on what comprises to­rus fracture (speaker has seen cases where complete distal radius fracture misdiagnosed as torus fracture); on x-ray, “speed bump” on one side of bone indicates torus fracture

Elbow injuries: swollen elbow has ³70% chance of being fractured, so do not manipulate; supracondylar most com­mon elbow fracture in children, proximal radius second most common; radial neck fracture may not produce much swelling; pitfall  —  elbow x-ray difficult to interpret; rely on clinical examination; pearl  —  “no such thing as small flecks of bone” (indicates fracture)

Limping child after minor trauma: 3 fractures common at £5 yr of age (but uncommon at >5 yr of age)  —  “toddler’s fracture” of tibial shaft; metatarsal fracture in foot; calcaneal fracture; physical examination (PE)  —  keep child calm; lay hands on legs and feel lightly for warmth or edema (1-finger examination); careful PE better than magnetic resonance imaging (MRI)

Splinting or casting: sometimes put cast on child simply because of greater efficacy; have predetermined end point (eg, what will be done if child still limping after 1 wk)

C-reactive protein (CRP) test: if ordering for suspected joint infection, need results immediately

When ordering x-rays: remember center of beam (joints above and below); get anteroposterior (AP), lateral, and oblique views on all elbows and fingers; weight-bearing joints should be taken in weight-bearing positions when­ever possible; pitfalls — Ewing’s sarcoma may be present in distal femur just above area visualized in knee x-ray; be cautious about accepting x-ray report stating “knee normal”; study found failure to palpate most common reason for missed or delayed diagnosis of tumors in distal femur or thigh

Growing pains: generally experienced at night (do not carry over into or limit activity during day); bilateral; have no swelling; over shins; cause debatable

Additional pearls: small fleck of bone at bottom of patella indicates displaced fracture; with tibial fractures, always be suspicious of nonaccidental injury

Common Sports Injuries and Return to Play

Dr. Kruse

Fracture of tibial spine: tibial spine within knee; site of attachment of anterior cruciate ligament (ACL) to proximal tibia; only signs of fracture may be small fleck of bone on x-ray and swollen knee; childhood equivalent of ACL tear; referral required

Cozen fracture: fracture of proximal tibial metaphysis; seen in children who twist leg; part of differential diagnosis of “toddler’s fracture”; requires casting; leg grows noticeably crooked after fracture heals in »10% of patients, but may resolve

Comments: fractures rarely occur near joints without history of significant trauma (if seen in nonwalking children, suspect nonaccidental injury); all patients with pain must be followed until resolution or until physician satisfied that work-up has been exhaustive; leukemia can present as bone pain  

Management of obese child who presents with hip or knee pain: follow pediatric principles (ie, hip may be source of knee pain, back may be source of hip pain); these children often have abnormal gait due to body habitus, so be cautious when examining hip; knee pain usually fairly distinct; x-ray should be AP “frog-leg” view of pelvis 

Ankle injuries: fractures  —  pain over bone indicates fracture, not sprain; swelling over lateral malleolus also indica­tive of fracture; sprains  —  diagnosis of exclusion

Metatarsal stress fractures: symptoms resolve in »4 wk; children return to sports too quickly and reinjure metatar­sus; for this reason, speaker recommends caution and additional time before letting patients with simple metatarsal fractures return to high-level running sports

Pitfalls in treating obese patients: common to fail to appreciate their pain and limitation of motion because of rela­tive lack of activity

Developmental dysplasia of hip (DDH): perform Ortolani-Barlow screening test by sweeping hand up from back into acetabulum, and from acetabulum out; ultrasonography (US) preferred imaging modality for screening; if PE inadequate due to uncooperative infant, re-examination required; speaker recommends US screening in all breach babies (or when family history positive for DDH); if not floridly dislocated, hip tends to resolve in otherwise nor­mal child; if hip subluxatable or just slightly loose on initial PE, monitor patient and repeat US and PE at 2 to 4 wk; if normal, problem resolved; if findings abnormal or  with other concerns, refer child to orthopedist

Advising parents about allowing child to return to sports: using best professional judgment, follow child weekly or biweekly for injury; give parents approximate timeline for treatment and rehabilitation

Sports in perspective: sports provide outlet for children and aid development; however, large number of kids decline to participate upon reaching adolescence; societal issues influence changes currently seen in childhood sports; fo­cus has shifted to individual athletes; speaker cites studies and articles suggesting parents’ behavior has become “out of control” at children’s games; National Federation of State High School Associations (NFHS) has good guidelines for participation; majority of sports injuries due to overuse; adults can be enablers (by pushing kids too hard); pediatric sports injuries rare until adults got involved; most common injuries in children are sprains and strains; injuries tend to be process, not discrete event (unless acute trauma occurred)

Timeline for healing: soft tissue injuries  —  immobilization and rest recommended for first 2 to 3 wk after initial in­jury; after this period, start gentle motion (early motion can delay stiffness); bone  —  after »2 wk, some fracture healing occurs in young children; with many stable fractures, can start movement or weightbearing after 2 to 3 wk; be aware of comorbidities that may affect healing   

General guidelines for return to sports: muscle and tendon soft tissue injury  —  must be pain-free and have near-normal strength and range of motion; bone injury  —  early healing of fracture with stability required (cast does not necessarily preclude participation)

When to stop activity: concept of relative rest; if child has pain that resolves shortly after starting or stopping activ­ity, no restrictions indicated; if child has persistent pain, joint instability, significant effusion, or pain or limitation that significantly alters gait, range of motion, strength, or reaction time, must stop activity; medical, not parental decision

Conditions that preclude return to play: swelling; deviation from normal range of motion; hemorrhage; athlete re­quires assistance to get around; athlete states he or she cannot continue

Therapy: rehabilitation begins with “pre-hab”; physical therapy modalities  —  work within patient’s pain-free range of motion; ice modality of choice for managing acute injuries; cold water immersions after heavy exercise found to decrease myositis and muscle damage; no data support benefit of heat for acute injury, but therapeutic heat can be helpful later during rehabilitation; if pain occurs after exercise, ice injury; if child previously trained, can return to »25% of previous activity level; when sending patient to therapist, be sure therapist has authority to evaluate and treat; therapists tend to use US

Guidelines for specific sports injuries: tear in acromioclavicular (AC) joint  —  child can return to sport when pain­free with regular range of motion; traumatic dislocation of shoulder  —  keep child out »6 wk; forearm and elbow  —no good data supporting role of bracing for returning fractures in upper and lower extremity; knee  —  medial collat­eral ligament (MCL) most common ligament torn; injury generally requires symptomatic treatment; child can re­turn when asymptomatic and he or she meets guidelines for inflammation and range of motion; meniscus  —  can sustain tear in twisting injury; if tear small and does not require repair, child can return when pain-free; if tear re­quires surgery, wait »6 wk for collagen to fully heal; ACL injury  —generally requires reconstruction; in standard approach, reconstruction delayed until skeletal maturity; if knee stable, child can start returning to activity; if unsta­ble, must keep child out of sport; in general, patient can return to full activity 6 to 12 mo after reconstructive sur­gery; ankle  —  take injuries seriously (immobilize, rehabilitate, and protect); stress fractures  —  time of return to sport variable (4-6 wk for metatarsal fracture, 6-8 wk for tibial fracture); return should be gradual

Orthopedic Preparticipation
Physical Examination (PE)

James G. Garrick, MD, Professor of Pediatrics, University of California, San Francisco, School of Medicine

Introductory remarks: no evidence-based orthopedic preparticipation PE for student athletes; “common sense” ap­proach developed »30 yr ago and still in use; preseason medical history  —  students do not like to report problems, and parents’ recollection of children’s medical history not accurate or reliable; medical history itself more accurate than PE 

Conducting examination: performed as mass screening examination; examine students individually; do not attempt directed examination during screening (in event of positive finding, refer student to another examiner; consists pri­marily of no-touch examination for symmetry

Elements of examination: shoulder height (shoulders should be approximately same height; if not, student may have had clavicular injury, or may have unilateral muscle weakness or spasm); indentation of waist; quadriceps mus­cles (have student tighten muscles and check for symmetry; probably most sensitive test for finding significant knee problems)

Have student look at floor, at ceiling, over each shoulder, and place ear on each shoulder: to assess cervical range of motion; particularly important in football players and wrestlers (frequently sustain cervical spine injuries); have students raise arms from sides; shoulders should stay at same height through 90°; if one shoulder goes up before 90°, impingement (usually due to weakness in rotator cuff) indicated; student requires more directed examina­tion; placing student in resisted abduction position and externally rotating shoulder in 90° abduction position can help identify shoulder weakness or previous dislocations

Have student straighten and fully flex elbows: check for full extension; lack of terminal extension associated with many elbow problems, especially in gymnasts; loss of terminal flexion also associated with previous elbow in­jury (flexion should be symmetrical)

Have student turn palms up, then pronate wrist: loss of rotation indicates previous wrist or elbow injury

Look at hands with fingers fully spread: note and record crooked fingers or abnormalities (to avoid later claims against academic institution for injury that purportedly occurred while student participating in sports)

Have student make fist: knuckles should be even (if not, may indicate previous metacarpal fracture)

Turn student around: look at waist indentation; look at scapulae (previous shoulder injury often results in slight winging of scapulae)

Have student: bend forward  —  look for rib humps and signs of scoliosis; fingers do not need to touch floor; how student bends over and straightens up may indicate back problems (coming up more important than bending down); stand on toes  —  look at gastrocnemius musculature; unilateral atrophy may indicate unresolved ankle sprain); rise on toes  —  to check dorsiflexion strength and balance); drop into heels-on-buttock squat  —  determine whether student can squat symmetrically (with knee problem, not able to get into full squat); also note how stu­dent comes out of squat (if done asymmetrically, may indicate patellar problem); “duck walk”  —  good test for meniscal disease; if student can duck walk symmetrically 2 or 3 steps, good indicator of knee health; unwilling­ness to perform on one side pinpoints which meniscus hurts

Concluding comments: sensitivity and specificity of preparticipation PE leave much to be desired; examination does provide coverage for administrative needs and legal documentation; however, in numerous studies, examinations have failed to show efficacy as predictors of injury; examination does provide valuable information for coaches on student’s ability to participate in sport

Suggested Reading

Carson S et al: Pediatric upper extremity injuries. Pediatr Clin North Am 53(1):41, 2006; Cassas KJ, Cassettari-Wayhs A: Childhood and adolescent sports-related overuse injuries. Am Fam Physician 73(6):1014, 2006; Crowther M: Elbow pain in pediatrics. Curr Rev Musculoskelet Med 2(2):83, 2009; Eriksson E: Anterior cruciate ligament tears in children and adoles­cents. Knee Surg Sports Traumatol Arthros 14(9):795, 2006; Garrick JG: Preparticipation orthopedic screening evaluation. Clin J Sport Med 14(3):123, 2004; Gelfer P, Kennedy KA: Developmental dysplasia of the hip. J Pediatr Health Care 22(5):318, 2008; Heyworth BE, Green DW: Lower extremity stress fractures in pediatric and adolescent athletes. Curr Opin Pediatr 20(1):58, 2008; Jones MH et al: Pediatric knee fractures. Curr Opin Pediatr 17(1):43,2005; Kocher MS, Tucker R: Pediatric athlete hip disorders. Clin Sports Med 25(2):241, 2006; Leung AK, Lemay JF: The limping child. J Pediatr Health Care 18(5):219, 2004; Lively MW: Preparticipation physical examinations: a collegiate experience. Clin J Sport Med 9(1):3, 1999; Malanga GA, Ramirez-Del Toro JA: Common injuries of the foot and ankle in the child and adolescent athlete. Phys Med Rehabil Clin N Am 19(2):347, 208; Metzl JD: The adolescent preparticipation physical examination. Is it helpful? Clin Sports Med 19(4):577, 2000; Pontell D et al: Sports injuries in the pediatric and adolescent foot and ankle: common overuse and acute presentations. Clin Podiatr Med Surg 23(1):209, 2006; Schachter AK, Rokito AS: ACL injuries in the skeletally immature patient. Orthopedics 30(5):365, 2007; Swischuk LE: The limping infant: imaging and clinical evaluation of trauma. Emerg Radiol 14(4):219, 2007; Waite BL, Krabak BJ: Examination and treatment of pediatric injuries of the hip and pelvis. Phys Med Rehabil Clin N Am 19(2):305, 2008; Wingfield K et al: Preparticipation evaluation: an evidence-based review. Clin J Sport Med 14(3):109, 2004; Wyndham M: The limping child. Community Pract 80(9):42, 2007.